(a) The Department shall adopt rules to develop, amend, and adopt medical coverage policy for Medicaid in accordance with this section.
(b) Medical coverage policy is defined as those policies, definitions, or guidelines utilized to evaluate, treat, or support the health or developmental conditions of a recipient so as to determine eligibility, authorization or continued authorization, medical necessity, course of treatment and supports, clinical outcomes, and clinical supports treatment practices for a covered procedure, product, or service. Medical coverage policy is subject to the following:
(1) During the development of new medical coverage policy or amendment to existing medical coverage policy, the Department shall consult with and seek the advice of the Physician Advisory Group and other organizations the Secretary deems appropriate. The Secretary shall also consult with and seek the advice of officials of the professional societies or associations representing providers who are affected by the new medical coverage policy or amendments to existing medical coverage policy.
(2) At least 45 days prior to the adoption of new or amended medical coverage policy, the Department shall:
a. Publish the proposed new or amended medical coverage policy on the Department's Web site;
b. Notify all Medicaid providers of the proposed, new, or amended policy; and
c. Upon request, provide persons copies of the proposed medical coverage policy.
(3) During the 45-day period immediately following publication of the proposed new or amended medical coverage policy, the Department shall accept oral and written comments on the proposed new or amended policy.
(4) If, following the comment period, the proposed new or amended medical coverage policy is modified, then the Department shall, at least 15 days prior to its adoption:
a. Notify all Medicaid providers of the proposed policy;
b. Upon request, provide persons notice of amendments to the proposed policy; and
c. Accept additional oral or written comments during this 15-day period.
(c) If the adoption of new or amended medical coverage policies is necessitated by an act of the General Assembly or a change in federal law, then the 45- and 15-day time periods specified in subsection (b) of this section shall instead be 30- and 10-day time periods.
(d) Repealed by Session Laws 2015-245, s. 19, effective September 23, 2015. (2006-66, s. 10.4; 2009-451, s. 10.68A(b); 2011-399, s. 4; 2013-360, s. 12H.6(a); 2015-245, s. 19; 2022-74, s. 9D.15(z).)
§ 108A-54.3: Repealed by Session Laws 2013-360, s. 12H.6(b), effective July 26, 2013.
§ 108A-54.3A. Eligibility categories and income thresholds.
(a) The Department shall provide Medicaid coverage for individuals in accordance with federal statutes and regulations and specifically shall provide coverage for the following populations:
(1) Families, children under the age of 21, pregnant women, and individuals who are aged, blind, or disabled, who are medically needy, subject to the following annual income levels after meeting the applicable deductible:
Family Size Income Level
1 $2,904
2 3,804
3 4,404
4 4,800
5 5,196
6 5,604
7 6,000
8 6,300
9 6,504
10 6,900
11 7,200
12 7,596
13 8,004
14 8,400
each additional family member add $396
(2) Families and children under the age of 21, subject to the following annual income levels:
Family Size Income Level
1 $5,208
2 6,828
3 8,004
4 8,928
5 9,888
6 10,812
7 11,700
8 12,432
9 13,152
10 14,028
each additional family member add $936
(2a) Repealed by Session Laws 2024-1, s. 3.3(c), effective July 1, 2022.
(3) Children through the age of 18 with family incomes equal to or less than two hundred eleven percent (211%) of the federal poverty guidelines.
(4) Repealed by Session Laws 2023-11, s. 3.2(c), effective April 1, 2023.
(5) Children under the age of 21 who are receiving foster care or adoption assistance under Title IV-E of the Social Security Act, without regard to income.
(6) Children in the legal custody of State-sponsored foster care who are under the age of 21 and ineligible for Title IV-E assistance, without regard to income.
(7) Independent foster care adolescents ages 18, 19, and 20, as defined in 42 U.S.C. § 1396d(w)(1), without regard to income.
(8) Former foster care children under the age of 26 in accordance with 42 U.S.C. § 1396a(a)(10)(A)(i)(IX), without regard to income.
(9) Adoptive children with special or rehabilitative needs, regardless of the adoptive family's income.
(10) (Effective until March 31, 2027.) Pregnant women with incomes equal to or less than one hundred ninety-six percent (196%) of the federal poverty guidelines. Pregnant women shall remain eligible for coverage for 12 months postpartum.
(10) (Effective March 31, 2027.) Pregnant women with incomes equal to or less than one hundred ninety-six percent (196%) of the federal poverty guidelines. Coverage for pregnant women eligible under this subdivision include only services related to pregnancy and to other conditions determined by the Department as conditions that may complicate pregnancy.
(11) Men and women of childbearing age with family incomes equal to or less than one hundred ninety-five percent (195%) of the federal poverty guidelines. Coverage for the individuals described in this subdivision shall be limited to coverage for family planning services.
(12) Women who need treatment for breast or cervical cancer and who are defined in 42 U.S.C. § 1396a(a)(10)(A)(ii)(XVIII).
(13) Aged, blind, or disabled individuals, as defined in Subpart F of Part 435 of Subchapter C of Chapter IV of Title 42 of the Code of Federal Regulations, with incomes equal to or less than one hundred percent (100%) of the federal poverty guidelines.
(14) Beneficiaries receiving supplemental security income under Title XVI of the Social Security Act.
(15) Workers with disabilities, as provided in G.S. 108A-66.1.
(16) Qualified working disabled individuals, as provided in G.S. 108A-67.
(17) Qualified Medicare beneficiaries with incomes equal to or less than one hundred percent (100%) of the federal poverty guidelines. Coverage for the individuals described in this subdivision shall be limited to payment of Medicare premiums and deductibles and coinsurance for Medicare-covered services.
(18) Specified low-income Medicare beneficiaries with incomes equal to or less than one hundred twenty percent (120%) of the federal poverty guidelines. Coverage for the individuals described in this subdivision shall be limited to payment of Medicare Part B premiums.
(19) Qualifying individuals who are Medicare beneficiaries and who have incomes equal to or less than one hundred thirty-five percent (135%) of the federal poverty guidelines may be covered within funds available for the Limited Medicare-Aid Capped Enrollment program. Coverage for the individuals described in this subdivision shall be limited to payment of Medicare Part B premiums.
(20) Recipients of an optional State supplementation program provided in accordance with 42 U.S.C. § 1382e.
(21) Individuals who meet eligibility criteria under a Medicaid waiver approved by the Centers for Medicare and Medicaid Services and authorized by an act of the General Assembly, within funds available for the waiver.
(22) Refugees, in accordance with 8 U.S.C. § 1522.
(23) Qualified aliens subject to the five-year bar for means tested public assistance under 8 U.S.C. § 1613 and undocumented aliens, only for emergency services under 8 U.S.C. § 1611.
(24) Individuals described in section 1902(a)(10)(A)(i)(VIII) of the Social Security Act who are in compliance with any federally approved work requirements established in the State Plan and in rule. Coverage for individuals under this subdivision is available through an Alternative Benefit Plan that is established by the Department consistent with federal requirements, unless that individual is exempt from mandatory enrollment in an Alternative Benefit Plan under 42 C.F.R. § 440.315.
(b) The applicable federal poverty guidelines for the eligibility categories in subsection (a) of this section shall be updated annually on April 1 immediately following publication of the federal poverty guidelines. (2020-78, s. 4D.1; 2021-62, s. 4.3; 2021-180, ss. 9D.13(a), 9D.14(b); 2022-74, ss. 9D.14(e), 9D.15(c); 2023-7, s. 1.1(b); 2023-11, s. 3.2(a), (c); 2023-134, s. 9E.23(c1), (e1); 2024-1, s. 3.3(c).)
§ 108A-54.3B. Nonfederal share of NC Health Works costs.
(a) As used in this section, the following definitions apply:
(1) Cost. - All expenses incurred by the State and counties that are eligible for Medicaid federal financial participation.
(2) NC Health Works. - The provision of Medicaid coverage to the individuals described in G.S. 108A-54.3A(a)(24).
(b) It is the intent of the General Assembly to fully fund the nonfederal share of the cost of NC Health Works through a combination of the following sources:
(1) Increases in revenue from the gross premiums tax under G.S. 105-228.5 due to NC Health Works.
(2) Excluding any State retention, the increases in intergovernmental transfers due to NC Health Works.
(3) Excluding any State retention, the hospital health advancement assessments under Part 3 of Article 7B of Chapter 108A of the General Statutes.
(4) Savings to the State attributable to NC Health Works that correspond to State General Fund budget reductions to other State programs.
(c) By February 1 of each year, beginning in 2025, the Department shall submit a report to the Joint Legislative Oversight Committee on Medicaid, the Office of State Budget and Management, and the Fiscal Research Division containing all of the following information with supporting calculations:
(1) The total nonfederal share of the cost of NC Health Works for the preceding State fiscal year and the total funding available from the sources described in subsection (b) of this section.
(2) The projected total nonfederal share of the cost of NC Health Works for the current State fiscal year and the total projected funding available from the sources described in subsection (b) of this section.
(3) The method used by the Department to determine the amount of the health advancement assessments proceeds that were distributed to each county department of social services in compliance with G.S. 108A-147.13(b) for the preceding fiscal year, including the total amount of proceeds each county received in that fiscal year.
(4) The savings and benefits to the State resulting from NC Health Works for the preceding fiscal year, including savings to various State agencies and programs.
The Department shall submit detailed data supporting any calculations contained in the report to the Fiscal Research Division.
(d) If, for any fiscal year, the nonfederal share of the cost of NC Health Works cannot be fully funded through the sources described in subsection (b) of this section, then Medicaid coverage for the category of individuals described in G.S. 108A-54.3A(a)(24) shall be discontinued as expeditiously as possible. Upon a determination by the Secretary that the nonfederal share of the cost of NC Health Works exceeds the funding from the sources described in subsection (b) of this section, the Secretary shall promptly do all of the following:
(1) Notify the Joint Legislative Oversight Committee on Medicaid, the Office of State Budget and Management, and the Fiscal Research Division of the determination and post this notice on the Department's website. The notice must include the proposed effective date of the discontinuation of coverage.
(2) Submit all documents to the Centers for Medicare and Medicaid Services necessary to discontinue Medicaid coverage for the category of individuals described in G.S. 108A-54.3A(a)(24). (2023-7, s. 1.2(a); 2023-134, s. 9E.23(c2).)
§ 108A-54.3C. NC Health Works federal financial participation.
If the federal medical assistance percentage for Medicaid coverage provided to the category of individuals described in G.S. 108A-54.3A(a)(24) falls below ninety percent (90%), then Medicaid coverage for this category of individuals shall be discontinued as expeditiously as possible but no earlier than the date the lower federal medical assistance percentage takes effect. Upon receipt of information indicating that the federal medical assistance percentage will be lower than ninety percent (90%), the Secretary shall promptly do all of the following:
(1) Notify the Joint Legislative Oversight Committee on Medicaid, the Office of State Budget and Management, and the Fiscal Research Division of the determination and post this notice on the Department's website. The notice must include the proposed effective date of the discontinuation of coverage.
(2) Submit all documents to the Centers for Medicare and Medicaid Services necessary to discontinue Medicaid coverage for the category of individuals described in G.S. 108A-54.3A(a)(24). (2023-7, s. 1.2(a); 2023-134, s. 9E.23(c2).)